PHC OUT-OF-NETWORK REFERRAL REQUEST FORM

Reminders
- Non-HMSA and out-of-state providers require an HMSA Administrative Review. PLEASE SUBMIT DIRECTLY TO HMSA FOR APPROVAL (Download Form) or call (808) 948-6464.
- Be aware of HMSA benefit caps on PT/OT services
- Please pre-certify services and products with HMSA's current guidelines
- Payment is subject to plan benefits and member eligibility at time of service

PACIFIC HEALTH CARE (PHC) | HMSA HMO

PART I & II REQUIRED
Part I - Patient Information
Today's Date*

YearMonthDay
Date
Hour Minutes
Status (URGENT: response needed within 3 business days, STAT: response needed within 24 hours due to medical necessity)*

Non-UrgentUrgentSTAT
Clinical reason for STAT*

Note: Appointment/Scheduling is not considered medically urgent0/100
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Insurance Number*
Patient's PCP*

First NameLast Name
Requesting PHC Provider*

First NameLast Name
Note: Authorized signers must be a PMAG Provider or their staff
Authorized Signature*

Clear
Contact Person*
Phone Number*
Fax Number*
Please enter a valid phone number.
Reason for Referring Out-of-Network*

Continuity of CarePatient PreferencePatient Referred SelfNo PHC Provider AvailableNo Other HMO Provider Available
Further Explanation Required*

Note: Additional documentation may be required and requested. Insufficient information may delay processing of your referral.0/200
Part II - Referring Patient To

Note: Non-HMSA and out-of-state providers require an HMSA Administrative Review.
Rendering Provider*

First NameLast Name
Phone Number*
Specialty / Specialties*
Location*

Street Address

Street Address Line 2

CityState

Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Diagnosis (descriptions only)*
Requested Services (check all that apply)*

Office ConsultationFollow Up Visit(s)Hospital Visit(s)RehabilitationDurable Medical EquipmentLaboratoryPharmacyInejctablesSleep StudyOther
DISCLAIMER: APPROVAL DOES NOT GUARANTEE PAYMENT OF CLAIM.
Should be Empty:

Reminders

PACIFIC HEALTH CARE (PHC) | HMSA HMO

Part I - Patient Information

Part II - Referring Patient To